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Kavaklı K, Antmen B, Okan V, Şahin F, Aytaç S, Balkan C, Berber E, Kaya Z, Küpesiz A, Zülfikar B. Gene therapy in haemophilia: literature review and regional perspectives for Turkey. Ther Adv Hematol 2022; 13:20406207221104591. [PMID: 35898436 PMCID: PMC9310332 DOI: 10.1177/20406207221104591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 05/16/2022] [Indexed: 01/19/2023] Open
Abstract
Haemophilia is an X-linked lifelong congenital bleeding disorder that is caused by insufficient levels of factor VIII (FVIII; haemophilia A) or factor IX (FIX; haemophilia B) and characterized by spontaneous and trauma-related bleeding episodes. The cornerstone of the treatment, factor replacement, constitutes several difficulties, including frequent injections due to the short half-life of recombinant factors, intravenous administration and the risk of inhibitor development. While extended half-life factors and subcutaneous novel molecules enhanced the quality of life, initial successes with gene therapy offer a significant hope for cure. Although adeno-associated viral (AAV)-based gene therapy is one of the most emerging approaches for treatment of haemophilia, there are still challenges in vector immunogenicity, potency and efficacy, genotoxicity and persistence. As the approval for the first gene therapy product is coming closer, eligibility criteria for patient selection, multidisciplinary approach for optimal delivery and follow-up and development of new pricing policies and reimbursement models should be concerned. Therefore, this review addresses the unmet needs of current haemophilia treatment and explains the rationale and principles of gene therapy. Limitations and challenges are discussed from a global and national perspective and recommendations are provided to adopt the gene therapies faster and more sufficient for the haemophilia patients in developing countries like Turkey.
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Affiliation(s)
- Kaan Kavaklı
- Division of Hematology, Department of Pediatrics, Ege University Faculty of Medicine, Bornova, 35100 İzmir, Turkey
| | - Bülent Antmen
- Division of Hematology, Department of Pediatrics, Acıbadem Adana Hospital, Adana, Turkey
| | - Vahap Okan
- Division of Hematology, Department of Internal Diseases, Gaziantep University Faculty of Medicine, Gaziantep, Turkey
| | - Fahri Şahin
- Division of Hematology, Department of Internal Diseases, Ege Adult Hemophilia and Thrombosis Center, Ege University Faculty of Medicine, İzmir, Turkey
| | - Selin Aytaç
- Division of Hematology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Can Balkan
- Division of Hematology, Department of Pediatrics, Ege University Faculty of Medicine, İzmir, Turkey
| | - Ergül Berber
- Department of Molecular Biology and Genetics, İstanbul Arel University, İstanbul, Turkey
| | - Zühre Kaya
- Division of Hematology, Department of Pediatrics, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Alphan Küpesiz
- Division of Hematology, Department of Pediatrics, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Bülent Zülfikar
- Division of Hematology, Department of Pediatrics, İstanbul University Faculty of Medicine, İstanbul, Turkey
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Lissitchkov T, Willemze A, Katragadda S, Rice K, Poloskey S, Benson C. Efanesoctocog alfa for hemophilia A: results from a phase 1 repeat-dose study. Blood Adv 2022; 6:1089-1094. [PMID: 34794179 PMCID: PMC8864644 DOI: 10.1182/bloodadvances.2021006119] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 10/28/2021] [Indexed: 11/22/2022] Open
Abstract
Efanesoctocog alfa (rFVIIIFc-VWF-XTEN; BIVV001) is a new class of factor VIII (FVIII) replacement that breaks the von Willebrand factor-imposed FVIII half-life ceiling. In a phase 1/2a study, single-dose efanesoctocog alfa was well tolerated, and no safety concerns were identified. We evaluated the safety, tolerability, and pharmacokinetics of repeat-dose efanesoctocog alfa in a phase 1 study in previously treated adults (≥150 exposure days) with severe hemophilia A. Participants received 4 once weekly doses of efanesoctocog alfa (cohort 1, 50 IU/kg; cohort 2, 65 IU/kg). All enrolled participants (cohort 1, n = 10; cohort 2, n = 14) completed the study. Inhibitor development to FVIII was not detected. After the last dose of efanesoctocog alfa, geometric mean (range) FVIII activity half-life, area under the activity-time curve, and steady-state maximum concentration for cohort 1 and cohort 2 were 41.3 (34.2-50.1) and 37.3 (28.9-43.8) hours, 8290 (5810-10 300) and 11 200 (7040-15 800) hours × IU/dL, and 131 (96-191) and 171 (118-211) IU/dL, respectively. There was minimal accumulation after 4 doses. Mean FVIII activity for cohort 1 and cohort 2, respectively, was 46% and 69% on day 3 postdose and 10% and 12% on day 7 postdose. Overall, 4 once-weekly doses of efanesoctocog alfa were well tolerated, no safety concerns were identified, and no bleeds were reported during the treatment period. Once-weekly efanesoctocog alfa provided high sustained FVIII activity within the normal to near-normal range for 3 to 4 days postdose and may improve protection against bleeds in patients with hemophilia A. The trial is study 2018-001535-51 in the EU Clinical Trials Register.
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Affiliation(s)
- Toshko Lissitchkov
- Department of Chemotherapy, Hemotherapy, and Hereditary Blood Diseases at Clinical Hematology Clinic, Specialized Hospital for Active Treatment of Hematological Diseases, Sofia, Bulgaria
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BIVV001, a new class of factor VIII replacement for hemophilia A that is independent of von Willebrand factor in primates and mice. Blood 2020; 135:1484-1496. [PMID: 32078672 DOI: 10.1182/blood.2019001292] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 01/29/2020] [Indexed: 01/19/2023] Open
Abstract
Factor VIII (FVIII) replacement products enable comprehensive care in hemophilia A. Treatment goals in severe hemophilia A are expanding beyond low annualized bleed rates to include long-term outcomes associated with high sustained FVIII levels. Endogenous von Willebrand factor (VWF) stabilizes and protects FVIII from degradation and clearance, but it also subjects FVIII to a half-life ceiling of ∼15 to 19 hours. Increasing recombinant FVIII (rFVIII) half-life further is ultimately dependent upon uncoupling rFVIII from endogenous VWF. We have developed a new class of FVIII replacement, rFVIIIFc-VWF-XTEN (BIVV001), that is physically decoupled from endogenous VWF and has enhanced pharmacokinetic properties compared with all previous FVIII products. BIVV001 was bioengineered as a unique fusion protein consisting of a VWF-D'D3 domain fused to rFVIII via immunoglobulin-G1 Fc domains and 2 XTEN polypeptides (Amunix Pharmaceuticals, Inc, Mountain View, CA). Plasma FVIII half-life after BIVV001 administration in mice and monkeys was 25 to 31 hours and 33 to 34 hours, respectively, representing a three- to fourfold increase in FVIII half-life. Our results showed that multifaceted protein engineering, far beyond a few amino acid substitutions, could significantly improve rFVIII pharmacokinetic properties while maintaining hemostatic function. BIVV001 is the first rFVIII with the potential to significantly change the treatment paradigm for severe hemophilia A by providing optimal protection against all bleed types, with less frequent doses. The protein engineering methods described herein can also be applied to other complex proteins.
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Sinegre T, Trayaud A, Tardieu M, Fourneyron V, Talon L, Berger MG, Tillier M, Senectaire S, Gembara P, Barbin AL, Vaissade A, Lebreton A. Measurements of eftrenonacog alfa by 19 different combinations reagents/instrument: A single-centre study. Haemophilia 2020; 26:543-552. [PMID: 32314511 DOI: 10.1111/hae.14003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 03/19/2020] [Accepted: 03/30/2020] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Recombinant factor IX Fc fusion protein (rFIXFc) is an extended half-life concentrate for the treatment of haemophilia B (HB). rFIXFc activity monitoring is crucial in several clinical situations. However, differences were observed between one-stage clotting (OSC) and chromogenic assays, but not for all factor IX (FIX) concentrations. AIMS To compare rFIXFc measurements obtained using different instruments and common OSC and chromogenic asssays. METHODS FIX:C measurements were performed in rFIXFc-spiked plasma aliquots (targeted FIX levels of 1.5, 1, 0.5, 0.2, 0.05, 0.02 and 0.01 IU/mL) and plasma samples collected from two patients with HB at various time points after rFIXFc infusion, using three instruments (STA-R MAX, ACLTOP700 and CS2100i) and common clotting and chromogenic FIX:C assays. RESULTS The same reagent could give different FIX:C measurements when adapted to different instruments. Moreover, the same reagent/instrument combination could give different results depending of the FIX concentration. For OSC assays, only STA-Cephascreen on STA-R MAX and CS2100i, SynthAFax on ACLTOP 700 and Actin on CS2100i provided acceptable recoveries for all rFIXFc concentrations. The chromogenic assays ROX-FIX and Biophen FIX:C underestimated rFIXFc for concentrations lower than 0.05 and 0.2 IU/mL, respectively. CONCLUSIONS Our study demonstrates that the same reagent adapted to different instruments could lead to different rFIXFc values. As rFIXFc under/overestimation could be associated with inappropriate treatment or biased calculation of pharmacokinetic parameters, the reagent/instrument combination used by haemostasis laboratories should be considered and regularly evaluated by external quality assessment programmes.
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Affiliation(s)
- Thomas Sinegre
- Service d'Hématologie Biologique, CHU Clermont-Ferrand, Clermont-Ferrand, France.,INRA UMR 1019, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Adeline Trayaud
- Service d'Hématologie Biologique, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Maryse Tardieu
- Service d'Hématologie Biologique, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Virginie Fourneyron
- Service d'Hématologie Biologique, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Laurie Talon
- Service d'Hématologie Biologique, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Marc G Berger
- Service d'Hématologie Biologique, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Maxence Tillier
- Service d'Hématologie Biologique, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Stéphanie Senectaire
- Service d'Hématologie Biologique, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Piotr Gembara
- Centre de Ressources et Compétences des Maladies Hémorragiques Constitutionnelles, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Anne-Lise Barbin
- Centre de Ressources et Compétences des Maladies Hémorragiques Constitutionnelles, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Aurélie Vaissade
- Service d'Hématologie Biologique, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Aurélien Lebreton
- Service d'Hématologie Biologique, CHU Clermont-Ferrand, Clermont-Ferrand, France.,INRA UMR 1019, Université Clermont Auvergne, Clermont-Ferrand, France.,Centre de Ressources et Compétences des Maladies Hémorragiques Constitutionnelles, CHU Clermont-Ferrand, Clermont-Ferrand, France
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Guo XL, Chung TH, Qin Y, Zheng J, Zheng H, Sheng L, Wynn T, Chang LJ. Hemophilia Gene Therapy: New Development from Bench to Bed Side. Curr Gene Ther 2019; 19:264-273. [PMID: 31549954 DOI: 10.2174/1566523219666190924121836] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 06/30/2019] [Accepted: 08/12/2019] [Indexed: 12/19/2022]
Abstract
Novel gene therapy strategies have changed the prognosis of many inherited diseases in recent years. New development in genetic tools and study models has brought us closer to a complete cure for hemophilia. This review will address the latest gene therapy research in hemophilia A and B including gene therapy tools, genetic strategies and animal models. It also summarizes the results of recent clinical trials. Potential solutions are discussed regarding the current barriers in gene therapy for hemophilia.
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Affiliation(s)
- Xiao-Lu Guo
- Geno-immune Medical Institute, Shenzhen, China
| | | | - Yue Qin
- School of Medicine, University of Electronic Science and Technology of China, Sichuan, China
| | - Jie Zheng
- Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Huyong Zheng
- Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Liyuan Sheng
- PKU-HKUST Shenzhen-Hong Kong Institution, Shenzhen, China
| | - Tung Wynn
- Department of Pediatrics and Division of Hematology/Oncology, University of Florida, Gainesville, FL, United States
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Chowdary P, Carcao M, Holme PA, Jiménez‐Yuste V, Lentz SR, Møss J, Poulsen LH, Shen C, Tosetto A, Wheeler A, Santagostino E. Fixed doses of N8-GP prophylaxis maintain moderate-to-mild factor VIII levels in the majority of patients with severe hemophilia A. Res Pract Thromb Haemost 2019; 3:542-554. [PMID: 31294338 PMCID: PMC6611478 DOI: 10.1002/rth2.12220] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 04/11/2019] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND N8-GP is an extended half-life recombinant factor VIII developed for prophylaxis and treatment of bleeds in patients with hemophilia A. OBJECTIVE To assess pharmacokinetic (PK) characteristics of N8-GP in previously treated patients with severe hemophilia A, model the time spent at hemophilia thresholds of ≥1 and ≤5 IU/dL (moderate) or >5 IU/dL (mild) FVIII levels during N8-GP prophylaxis, and investigate the relationship between N8-GP half-life and von Willebrand factor (vWF). METHODS PK assessments were obtained from patients with severe hemophilia A (FVIII < 1 IU/dL) participating in 4 clinical trials: pathfinder 1 (20-60 years); pathfinder 2 (12-17 and ≥18 years); pathfinder 5 (0-11 years), and pathfinder 7 (25-71 years). All PK profiles were assessed after washout and considered single-dose PK profiles. Pre- and postdose FVIII activity at steady state was measured at all visits. RESULTS From 69 patients, 108 PK profiles of N8-GP 50 IU/kg were assessed. Adults/adolescents received 50 IU/kg every 4 days, achieving mean trough levels of 3.0 IU/dL (95% confidence interval, 2.6-3.5, adults) and 2.7 IU/dL (1.8-4.0, adolescents). Children received 60 IU/kg twice weekly, leading to mean trough levels of 1.2 IU/dL (0.8-1.6, 0- to 5-year-olds) and 2.0 IU/dL (1.5-2.7, 6- to 11-year-olds). PK modeling predicted children dosed every 3 days and adults/adolescents dosed every 3 to 4 days would maintain FVIII levels >5 and >1 IU/dL for >80% and 100% of the time, respectively. N8-GP half-life correlated linearly with von Willebrand factor levels in adults/adolescents, less in children. CONCLUSIONS Prophylaxis with fixed intervals (Q4D/twice weekly) and fixed weight-based dosing (50/60 IU/kg) ensured >1 IU/dL FVIII trough levels in both adults and children.
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Affiliation(s)
- Pratima Chowdary
- Katherine Dormandy Haemophilia Centre and Thrombosis UnitRoyal Free HospitalLondonUK
| | - Manuel Carcao
- Division of Haematology/Oncology and Child Health Evaluative SciencesResearch InstituteHospital for Sick ChildrenUniversity of TorontoTorontoOntarioCanada
| | - Pål A. Holme
- Department of HaematologyInstitute of Clinical MedicineUniversity of OsloOslo University HospitalOsloNorway
| | - Victor Jiménez‐Yuste
- Hospital Universitario La PazUnidad De CoagulopatíasServicio De HematologíaAutonoma UniversityMadridSpain
| | - Steven R. Lentz
- Division of Hematology, Oncology, and Blood & Marrow TransplantationDepartment of Internal MedicineUniversity of Iowa Carver College of MedicineIowa CityIAUSA
| | | | - Lone H. Poulsen
- Hemophilia CenterDepartment of HematologyAarhus University HospitalAarhusDenmark
| | | | - Alberto Tosetto
- Hemophilia and Thrombosis CenterHematology DepartmentSan Bortolo HospitalVicenzaItaly
| | - Allison Wheeler
- School of Medicine, Pathology, Microbiologyand Immunology, Vanderbilt UniversityNashvilleTNUSA
| | - Elena Santagostino
- Foundation IRCCS Cà Granda, Maggiore Hospital PolyclinicAngelo Bianchi Bonomi Hemophilia and Thrombosis CentreMilanItaly
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Santagostino E, Mancuso ME. GlycoPEGylated recombinant factor IX for hemophilia B in context. Drug Des Devel Ther 2018; 12:2933-2943. [PMID: 30254423 PMCID: PMC6141116 DOI: 10.2147/dddt.s121743] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Decisions over hemophilia treatment selection and switching involve balancing many clinical and patient-related factors. The current standard of care for patients with hemophilia B is prophylaxis with plasma-derived or recombinant factor IX (rFIX) concentrates. However, several extended half-life (EHL) rFIX products have recently been developed to improve treatment convenience and clinical outcomes for these patients. Nonacog beta pegol, an rFIX product that combines the FIX protein with a 40 kDa polyethylene glycol moiety, has been evaluated in 115 previously treated patients with hemophilia B (including 25 children) in the paradigm clinical trial program. FIX activity levels and pharmacokinetics were monitored throughout these trials and showed that nonacog beta pegol offers significant pharmacological improvements over standard FIX products. Once-weekly prophylaxis with nonacog beta pegol 40 IU/kg resulted in fewer bleeds in all patients (median annualized bleeding rate of 1.0 across all ages), resolved 90% of target joints, and improved health-related quality of life. No patients developed FIX inhibitors, and there were no thromboembolic events or unexpected safety concerns. Nonacog beta pegol was also safe and effective in the perioperative setting. These findings show that nonacog beta pegol is highly effective, while also offering more convenient dosing than standard FIX products. Nonacog beta pegol represents a significant advance in the current context of treatment for hemophilia B, offering effective management across several treatment modalities and settings, and potentially easing the treatment burden for patients of all ages. Meanwhile, the development of novel treatment strategies, such as gene therapy, anti-tissue factor pathway inhibitor antibodies, and RNA interference therapy, may provide patients with additional therapeutic options, which would require reassessment of the role of EHL products in the future.
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Affiliation(s)
- Elena Santagostino
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, IRCCS Ca' Granda Foundation, Maggiore Hospital Policlinic, Milan, Italy,
| | - Maria Elisa Mancuso
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, IRCCS Ca' Granda Foundation, Maggiore Hospital Policlinic, Milan, Italy,
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Oldenburg J, Carcao M, Lentz SR, Mahlangu J, Mancuso ME, Matsushita T, Négrier C, Clausen WHO, Ehrenforth S, Young G. Once-weekly prophylaxis with 40 IU/kg nonacog beta pegol (N9-GP) achieves trough levels of >15% in patients with haemophilia B: Pooled data from the paradigm™ trials. Haemophilia 2018; 24:911-920. [DOI: 10.1111/hae.13608] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 07/31/2018] [Accepted: 08/06/2018] [Indexed: 01/07/2023]
Affiliation(s)
- Johannes Oldenburg
- Institute of Experimental Haematology and Transfusion Medicine; University Clinic Bonn; Bonn Germany
| | - Manuel Carcao
- Division of Haematology/Oncology, Department of Paediatrics and Research Institute, Hospital for Sick Children; University of Toronto; Toronto Ontario Canada
| | - Steven R. Lentz
- Department of Internal Medicine, Carver College of Medicine; University of Iowa; Iowa City Iowa
| | - Johnny Mahlangu
- Haemophilia Comprehensive Care Centre, Faculty of Health Sciences; NHLS and University of the Witwatersrand; Johannesburg South Africa
| | - Maria Elisa Mancuso
- Angelo Bianchi Bonomi Haemophilia and Thrombosis Centre; Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico; Milan Italy
| | - Tadashi Matsushita
- Department of Transfusion Medicine; Nagoya University Hospital; Nagoya Japan
| | - Claude Négrier
- Haemophilia and Thrombosis Centre, Louis Pradel Hospital; University Claude Bernard; Lyon France
| | | | | | - Guy Young
- Hemostasis and Thrombosis Center, Children's Hospital Los Angeles; University of Southern California Keck School of Medicine; Los Angeles California
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Mahlangu J, Young G, Hermans C, Blanchette V, Berntorp E, Santagostino E. Defining extended half-life rFVIII-A critical review of the evidence. Haemophilia 2018; 24:348-358. [DOI: 10.1111/hae.13438] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2018] [Indexed: 01/23/2023]
Affiliation(s)
- J. Mahlangu
- Faculty of Health Sciences; University of the Witwatersrand and National Health Laboratory Service; Charlotte Maxeke Johannesburg Academic Hospital; Johannesburg South Africa
| | - G. Young
- Children's Hospital Los Angeles; University of Southern California Keck School of Medicine; Los Angeles CA USA
| | - C. Hermans
- Haemostasis and Thrombosis Unit; Division of Haematology; Cliniques universitaires Saint-Luc; Brussels Belgium
| | - V. Blanchette
- Pediatric Thrombosis and Hemostasis Program; Division of Hematology/Oncology; Hospital for Sick Children; University of Toronto; Toronto ON Canada
| | - E. Berntorp
- Centre for Thrombosis and Haemostasis; Lund University; Malmö Sweden
| | - E. Santagostino
- A. Bianchi Bonomi Hemophilia and Thrombosis Center; IRCCS Ca' Granda Foundation; Maggiore Hospital Policlinico of Milan; Milan Italy
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11
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Nathwani AC, Davidoff AM, Tuddenham EGD. Advances in Gene Therapy for Hemophilia. Hum Gene Ther 2017; 28:1004-1012. [DOI: 10.1089/hum.2017.167] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Amit C. Nathwani
- Department of Haematology, University College London Cancer Institute, London, United Kingdom
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London, United Kingdom
- NHS Blood and Transplant, Watford, United Kingdom
| | - Andrew M. Davidoff
- Department of Surgery, St. Jude Children's Research Hospital, Memphis Tennessee
| | - Edward G. D. Tuddenham
- Department of Haematology, University College London Cancer Institute, London, United Kingdom
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London, United Kingdom
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Abstract
The best currently available treatments for hemophilia A and B (factor VIII or factor IX deficiency, respectively) require frequent intravenous infusion of highly expensive proteins that have short half-lives. Factor levels follow a saw-tooth pattern that is seldom in the normal range and falls so low that breakthrough bleeding occurs. Most hemophiliacs worldwide do not have access to even this level of care. In stark contrast, gene therapy holds out the hope of a cure by inducing continuous endogenous expression of factor VIII or factor IX following transfer of a functional gene to replace the hemophilic patient's own defective gene.
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Affiliation(s)
- Amit C Nathwani
- Department of Academic Haematology, UCL Cancer Institute, Katharine Dormandy Haemophilia and Thrombosis Centre, Rowland Hill Street, London NW3 2PF, United Kingdom; National Health Service Blood and Transplant, Oak House, Reeds Crescent, Watford, Hertfordshire, WD24 4QN, United Kingdom.
| | - Andrew M Davidoff
- Department of Surgery, St. Jude Children's Research Hospital, 262 Danny Thomas Place Memphis, TN 38105-3678, USA
| | - Edward G D Tuddenham
- Department of Academic Haematology, UCL Cancer Institute, Katharine Dormandy Haemophilia and Thrombosis Centre, Rowland Hill Street, London NW3 2PF, United Kingdom
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13
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Nowak-Göttl U, Clausnizer H, Kowalski D, Limperger V, Krümpel A, Shneyder M, Reinke S, Rocke A, Juhl D, Steppat D, Krause M. Health-related quality of life in children, adolescents and adults with hereditary and acquired bleeding disorders. Blood Cells Mol Dis 2017; 67:96-101. [DOI: 10.1016/j.bcmd.2016.11.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 11/11/2016] [Indexed: 11/16/2022]
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Waters EK, Sigh J, Friedrich U, Hilden I, Sørensen BB. Concizumab, an anti-tissue factor pathway inhibitor antibody, induces increased thrombin generation in plasma from haemophilia patients and healthy subjects measured by the thrombin generation assay. Haemophilia 2017; 23:769-776. [PMID: 28594458 DOI: 10.1111/hae.13260] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2017] [Indexed: 02/04/2023]
Abstract
AIMS Concizumab, a humanized monoclonal antibody against tissue factor pathway inhibitor (TFPI), is being developed as a subcutaneously (s.c.) administered treatment for haemophilia. It demonstrated a concentration-dependent procoagulant effect in functional TFPI assays; however, global haemostatic assays, such as the thrombin generation assay (TGA), offer a more complete picture of coagulation. We investigated how concizumab affects thrombin generation following ex vivo spiking in plasma from haemophilia patients using the TGA, and if the assay can detect the effect of multiple s.c. concizumab doses in healthy subjects. METHODS For the ex vivo spiking study, platelet-poor plasma (PPP) from 18 patients with severe haemophilia was spiked with 0.001-500 nm concizumab. For the multiple-dosing study, four healthy males received concizumab 250 μg kg-1 s.c. every other day for eight doses; blood was collected before and after dosing and processed into PPP. In both studies, thrombin generation was measured using a Calibrated Automated Thrombogram® system with 1 pm tissue factor. RESULTS In spiked samples from haemophilia patients, peak thrombin and endogenous thrombin potential (ETP) increased concentration dependently, reaching near-normal levels at concizumab concentrations >10 nm. Repeated s.c. doses of concizumab in healthy subjects increased both peak thrombin and ETP; these effects were sustained throughout the dosing interval. CONCLUSIONS Thrombin generation assay demonstrated increased thrombin generation with concizumab after ex vivo spiking of haemophilia plasma and multiple s.c. doses in healthy subjects, supporting both the utility of the TGA in evaluating concizumab treatment and the potential of s.c. concizumab as a novel haemophilia therapy.
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Affiliation(s)
- E K Waters
- Haemophilia Biology, Novo Nordisk A/S, Måløv, Denmark
| | - J Sigh
- Haemophilia Biology, Novo Nordisk A/S, Måløv, Denmark
| | - U Friedrich
- Haemophilia Biology, Novo Nordisk A/S, Måløv, Denmark
| | - I Hilden
- Haemophilia Biology, Novo Nordisk A/S, Måløv, Denmark
| | - B B Sørensen
- Haemophilia Biology, Novo Nordisk A/S, Måløv, Denmark
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Di Minno G, Tremoli E. Tailoring of medical treatment: hemostasis and thrombosis towards precision medicine. Haematologica 2017; 102:411-418. [PMID: 28250003 DOI: 10.3324/haematol.2016.156000] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Giovanni Di Minno
- Clinica Medica, Dipartimento di Medicina Clinica e Chirurgia, Università degli Studi di Napoli "Federico II", Naples, Italy
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16
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Abstract
OBJECTIVE To describe a successful prophylactic protocol for managing an athlete with hemophilia playing at a high level of contact sports. BACKGROUND Published data show that team physicians are not comfortable either treating athletes with bleeding disorders or allowing them to participate in contact sports. Much of the literature historically has recommended against allowing athletes with bleeding disorders to play sports at all and certainly against playing contact sports. Hemophilia treatment can now include prophylactic injections of recombinant factor VIII to prevent bleeding episodes. Modern treatments hold the promise of allowing athletes with hemophilia to participate in contact sports. DIFFERENTIAL DIAGNOSIS Mild, moderate, or severe hemophilia; von Willebrand disease; other factor deficiencies. TREATMENT A treatment protocol was developed that included prophylactic factor VIII injections on a regular basis and when the athlete was injured. UNIQUENESS This is the first published case report of an athlete with known hemophilia being successfully treated and participating in National Collegiate Athletic Association collegiate basketball for 2 full seasons. CONCLUSIONS Sports medicine teams can successfully manage an athlete with hemophilia playing a contact sport.
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Affiliation(s)
- Mark Maffet
- Houston Methodist Orthopedics and Sports Medicine, TX
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17
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Carcao M, Zak M, Abdul Karim F, Hanabusa H, Kearney S, Lu MY, Persson P, Rangarajan S, Santagostino E. Nonacog beta pegol in previously treated children with hemophilia B: results from an international open-label phase 3 trial. J Thromb Haemost 2016; 14:1521-9. [PMID: 27174727 DOI: 10.1111/jth.13360] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Accepted: 04/12/2016] [Indexed: 01/17/2023]
Abstract
UNLABELLED Essentials Nonacog beta pegol is a recombinant glycoPEGylated factor IX with an extended half-life. This phase 3 trial investigated its safety/efficacy in previously treated hemophilia B boys ≤ 12 years. A 40 IU kg(-1) dose provided effective once-weekly prophylaxis and hemostasis when used to treat bleeds. Nonacog beta pegol was well tolerated in previously treated boys ≤ 12 years with hemophilia B. SUMMARY Background Nonacog beta pegol is a recombinant glycoPEGylated factor IX with an extended half-life, developed to improve care for patients with hemophilia B. Objectives To investigate the safety, efficacy and pharmacokinetics of nonacog beta pegol for the prophylaxis and treatment of bleeds in previously treated children with hemophilia B. Patients/Methods This phase 3 trial, paradigm(™) 5, enrolled and treated 25 children (aged ≤ 12 years) with hemophilia B (FIX ≤ 2%). Patients were stratified by age (0-6 years and 7-12 years), and received once-weekly prophylaxis with 40 IU kg(-1) nonacog beta pegol for 50 exposure days. Results No patient developed inhibitors, and no safety concerns were identified. Forty-two bleeds in 15 patients were reported to have been treated; the overall success rate was 92.9%, and most bleeds (85.7%) resolved after one dose. The median annualized bleeding rates (ABRs; bleeds per patient per year) were 1.0 in the total population, 0.0 in the 0-6-year group, and 2.0 in the 7-12-year group; the estimated mean ABRs were 1.44 in the total population, 0.87 in the 0-6-year group, and 1.88 in the 7-12-year group. For 22 patients who had previously been receiving prophylaxis, the estimated mean ABR was 1.38 versus a historical ABR of 2.51. Estimated mean steady-state FIX trough levels were 0.153 IU mL(-1) (0-6 years) and 0.190 IU mL(-1) (7-12 years). Conclusion Nonacog beta pegol was well tolerated in previously treated children with hemophilia B; a 40 IU kg(-1) dose provided effective once-weekly prophylaxis and hemostasis when bleeds were treated.
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Affiliation(s)
- M Carcao
- Division of Haematology/Oncology, Department of Paediatrics and Research Institute, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - M Zak
- Novo Nordisk A/S, Søborg, Denmark
| | - F Abdul Karim
- Hemophilia Center, National Blood Center, Kuala Lumpur, Malaysia
| | | | - S Kearney
- Hemophilia Treatment Center, Children's Hospital and Clinics of Minnesota, Minneapolis, MN, USA
| | - M-Y Lu
- NTUH, Children's and Women's Hospital, Taipei, Taiwan
| | | | - S Rangarajan
- Haemophilia, Haemostasis & Thrombosis Centre, Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK
| | - E Santagostino
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, IRCCS Ca' Granda Foundation, Maggiore Hospital Policlinico, Milan, Italy
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18
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Collins P, Chalmers E, Chowdary P, Keeling D, Mathias M, O'Donnell J, Pasi KJ, Rangarajan S, Thomas A. The use of enhanced half-life coagulation factor concentrates in routine clinical practice: guidance from UKHCDO. Haemophilia 2016; 22:487-98. [DOI: 10.1111/hae.13013] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2016] [Indexed: 01/19/2023]
Affiliation(s)
- P. Collins
- Arthur Bloom Haemophilia Centre; University Hospital of Wales; Cardiff UK
| | - E. Chalmers
- Haemophilia Centre; Royal Hospital for Sick Children; Glasgow UK
| | - P. Chowdary
- Katharine Dormandy Haemophilia Centre; Royal Free Hospital; London UK
| | - D. Keeling
- Haemophilia Centre; Churchill Hospital; Oxford UK
| | - M. Mathias
- Haemophilia Centre; Great Ormond Street Hospital; London UK
| | - J. O'Donnell
- Haemophilia Centre; St. James Hospital; Dublin Ireland
| | - K. J. Pasi
- Haemophilia Centre; Royal London Hospital; London UK
| | - S. Rangarajan
- Haemophilia Centre; Basingstoke and North Hampshire Hospital; Basingstoke UK
| | - A. Thomas
- Haemophilia Centre; Royal Infirmary of Edinburgh; Edinburgh UK
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19
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Nogami K. The utility of thromboelastography in inherited and acquired bleeding disorders. Br J Haematol 2016; 174:503-14. [PMID: 27264484 DOI: 10.1111/bjh.14148] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 03/30/2016] [Indexed: 01/08/2023]
Abstract
Thromboelastography (TEG) was first described by Hartert in 1948, and was designed to monitor viscoelastic clot strength in whole blood in real time. The current TEG method and Rotational Thromboelastometry (ROTEM) were subsequently developed from the original principles. Both of the modern methods provide data by measuring changes in the viscoelastic strength of a small sample of clotting blood in response to a constant rotational force. The important advantage of these techniques is to visually observe and quantify blood coagulation including the propagation, stabilization and dissolution phases of clot formation under low shear conditions. Analysis of the results provides detailed kinetic data on fibrin generation, clot strength and fibrinolysis. These TEG/ROTEM analyses therefore enable evaluation of global clotting function and the monitoring of haemostatic treatment in various clinical situations, not only in patients with genetic bleeding disorders, such as haemophilia, but also in patients undergoing cardiac surgery, liver transplantation or suffering from traumatic injury. Some evidence suggests that haemostatic management using TEG/ROTEM leads to a reduction in total transfusions of whole blood or clotting factors. Wider clinical application of this technology seems likely.
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Affiliation(s)
- Keiji Nogami
- Department of Paediatrics, Nara Medical University, Kashihara, Nara, Japan
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20
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Health-Related Quality of Life in Children and Adolescents with Hereditary Bleeding Disorders and in Children and Adolescents with Stroke: Cross-Sectional Comparison to Siblings and Peers. BIOMED RESEARCH INTERNATIONAL 2016; 2016:1579428. [PMID: 27294108 PMCID: PMC4884589 DOI: 10.1155/2016/1579428] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 04/07/2016] [Indexed: 11/17/2022]
Abstract
Objectives. To investigate self-reported health-related quality of life (HrQoL) in children and adolescents with chronic medical conditions compared with siblings/peers. Methods. Group 1 (6 treatment centers) consisted of 74 children/adolescents aged 8–16 years with hereditary bleeding disorders (HBD), 12 siblings, and 34 peers. Group 2 (one treatment center) consisted of 70 children/adolescents with stroke/transient ischemic attack, 14 siblings, and 72 peers. HrQoL was assessed with the “revised KINDer Lebensqualitätsfragebogen” (KINDL-R) questionnaire. Multivariate analyses within groups were done by one-way ANOVA and post hoc pairwise single comparisons by Student's t-tests. Adjusted pairwise comparisons were done by hierarchical linear regressions with individuals nested within treatment centers (group 1) and by linear regressions (group 2), respectively. Results. No differences were found in multivariate analyses of self-reported HrQoL in group 1, while in group 2 differences occurred in overall wellbeing and all subdimensions. These differences were due to differences between patients and peers. After adjusting for age, gender, number of siblings, and treatment center these differences persisted regarding self-worth (p = .0040) and friend-related wellbeing (p < .001). Conclusions. In children with HBD, HrQoL was comparable to siblings and peers. In children with stroke/TIA HrQoL was comparable to siblings while peers, independently of relevant confounder, showed better self-worth and friend-related wellbeing.
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21
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Lheriteau E, Davidoff AM, Nathwani AC. Haemophilia gene therapy: Progress and challenges. Blood Rev 2015; 29:321-8. [DOI: 10.1016/j.blre.2015.03.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 03/04/2015] [Indexed: 10/23/2022]
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22
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Ca2+ concentration-dependent conformational change of FVIII B-domain observed by atomic force microscopy. Anal Bioanal Chem 2015; 407:6051-6. [DOI: 10.1007/s00216-015-8778-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 05/07/2015] [Accepted: 05/08/2015] [Indexed: 11/26/2022]
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23
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Sørensen MH, Andersen S, Ezban M. Factor IX-deficient plasma spiked with N9-GP behaves similarly to N9-GP post-administration clinical samples in N9-GP ELISA and FIX activity assays. Haemophilia 2015; 21:832-6. [DOI: 10.1111/hae.12680] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2015] [Indexed: 01/06/2023]
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24
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Zeller MP, Al-Habsi KS, Golder M, Walsh GM, Sheffield WP. Plasma and Plasma Protein Product Transfusion: A Canadian Blood Services Centre for Innovation Symposium. Transfus Med Rev 2015; 29:181-94. [PMID: 25862281 DOI: 10.1016/j.tmrv.2015.03.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2015] [Revised: 03/12/2015] [Accepted: 03/13/2015] [Indexed: 12/27/2022]
Abstract
Plasma obtained via whole blood donation processing or via apheresis technology can either be transfused directly to patients or pooled and fractionated into plasma protein products that are concentrates of 1 or more purified plasma protein. The evidence base supporting clinical efficacy in most of the indications for which plasma is transfused is weak, whereas high-quality evidence supports the efficacy of plasma protein products in at least some of the clinical settings in which they are used. Transfusable plasma utilization remains composed in part of applications that fall outside of clinical practice guidelines. Plasma contains all of the soluble coagulation factors and is frequently transfused in efforts to restore or reinforce patient hemostasis. The biochemical complexities of coagulation have in recent years been rationalized in newer cell-based models that supplement the cascade hypothesis. Efforts to normalize widely used clinical hemostasis screening test values by plasma transfusion are thought to be misplaced, but superior rapid tests have been slow to emerge. The advent of non-vitamin K-dependent oral anticoagulants has brought new challenges to clinical laboratories in plasma testing and to clinicians needing to reverse non-vitamin K-dependent oral anticoagulants urgently. Current plasma-related controversies include prophylactic plasma transfusion before invasive procedures, plasma vs prothrombin complex concentrates for urgent warfarin reversal, and the utility of increased ratios of plasma to red blood cell units transfused in massive transfusion protocols. The first recombinant plasma protein products to reach the clinic were recombinant hemophilia treatment products, and these donor-free equivalents to factors VIII and IX are now being supplemented with novel products whose circulatory half-lives have been increased by chemical modification or genetic fusion. Achieving optimal plasma utilization is an ongoing challenge in the interconnected worlds of transfusable plasma, plasma protein products, and recombinant and engineered replacements.
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Affiliation(s)
- Michelle P Zeller
- Centre for Innovation, Medical Services and Innovation, Canadian Blood Services, Hamilton, Ottawa, Vancouver, Canada; Department of Medicine, McMaster University, Hamilton, Canada
| | - Khalid S Al-Habsi
- Centre for Innovation, Medical Services and Innovation, Canadian Blood Services, Hamilton, Ottawa, Vancouver, Canada; Department of Medicine, McMaster University, Hamilton, Canada
| | - Mia Golder
- Centre for Innovation, Medical Services and Innovation, Canadian Blood Services, Hamilton, Ottawa, Vancouver, Canada
| | - Geraldine M Walsh
- Centre for Innovation, Medical Services and Innovation, Canadian Blood Services, Hamilton, Ottawa, Vancouver, Canada
| | - William P Sheffield
- Centre for Innovation, Medical Services and Innovation, Canadian Blood Services, Hamilton, Ottawa, Vancouver, Canada; Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada.
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25
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Nathwani AC, Reiss UM, Tuddenham EGD, Rosales C, Chowdary P, McIntosh J, Della Peruta M, Lheriteau E, Patel N, Raj D, Riddell A, Pie J, Rangarajan S, Bevan D, Recht M, Shen YM, Halka KG, Basner-Tschakarjan E, Mingozzi F, High KA, Allay J, Kay MA, Ng CYC, Zhou J, Cancio M, Morton CL, Gray JT, Srivastava D, Nienhuis AW, Davidoff AM. Long-term safety and efficacy of factor IX gene therapy in hemophilia B. N Engl J Med 2014; 371:1994-2004. [PMID: 25409372 PMCID: PMC4278802 DOI: 10.1056/nejmoa1407309] [Citation(s) in RCA: 927] [Impact Index Per Article: 92.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND In patients with severe hemophilia B, gene therapy that is mediated by a novel self-complementary adeno-associated virus serotype 8 (AAV8) vector has been shown to raise factor IX levels for periods of up to 16 months. We wanted to determine the durability of transgene expression, the vector dose-response relationship, and the level of persistent or late toxicity. METHODS We evaluated the stability of transgene expression and long-term safety in 10 patients with severe hemophilia B: 6 patients who had been enrolled in an initial phase 1 dose-escalation trial, with 2 patients each receiving a low, intermediate, or high dose, and 4 additional patients who received the high dose (2×10(12) vector genomes per kilogram of body weight). The patients subsequently underwent extensive clinical and laboratory monitoring. RESULTS A single intravenous infusion of vector in all 10 patients with severe hemophilia B resulted in a dose-dependent increase in circulating factor IX to a level that was 1 to 6% of the normal value over a median period of 3.2 years, with observation ongoing. In the high-dose group, a consistent increase in the factor IX level to a mean (±SD) of 5.1±1.7% was observed in all 6 patients, which resulted in a reduction of more than 90% in both bleeding episodes and the use of prophylactic factor IX concentrate. A transient increase in the mean alanine aminotransferase level to 86 IU per liter (range, 36 to 202) occurred between week 7 and week 10 in 4 of the 6 patients in the high-dose group but resolved over a median of 5 days (range, 2 to 35) after prednisolone treatment. CONCLUSIONS In 10 patients with severe hemophilia B, the infusion of a single dose of AAV8 vector resulted in long-term therapeutic factor IX expression associated with clinical improvement. With a follow-up period of up to 3 years, no late toxic effects from the therapy were reported. (Funded by the National Heart, Lung, and Blood Institute and others; ClinicalTrials.gov number, NCT00979238.).
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26
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Mannucci PM. Half-life extension technologies for haemostatic agents. Thromb Haemost 2014; 113:165-76. [PMID: 25274414 DOI: 10.1160/th14-04-0332] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 08/27/2014] [Indexed: 12/18/2022]
Abstract
The use of plasma-derived and recombinant coagulation factors for the treatment of haemophilia A and B is well established and permits patients to live a relatively normal life. In order to improve treatment options, several products are in development, which have a prolonged duration of action, thus enabling less frequent prophylactic dosing and aiming to reduce the burden of treatment. Several innovative approaches are being pursued to extend the half-life of factor VIIa, factor VIII and factor IX, utilising technologies such as Fc fusion, recombinant albumin fusion and addition of polyethyleneglycol (PEG) (PEGylation). These methods prolong the time in the circulation by reducing degradation and elimination. This review summarises the technologies and products in development and their stages of development, and also discusses their pros and cons.
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Affiliation(s)
- Pier Mannuccio Mannucci
- Pier Mannuccio Mannucci, Scientific Director, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, IRCCS Cà Grande Maggiore Policlinico Hospital Foundation, Milan, Italy, Tel.: +39 02 55038377, Fax: +39 02 50320723, E-mail:
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27
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Anti-factor IXa/X bispecific antibody ACE910 prevents joint bleeds in a long-term primate model of acquired hemophilia A. Blood 2014; 124:3165-71. [PMID: 25274508 DOI: 10.1182/blood-2014-07-585737] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
ACE910 is a humanized anti-factor IXa/X bispecific antibody mimicking the function of factor VIII (FVIII). We previously demonstrated in nonhuman primates that a single IV dose of ACE910 exerted hemostatic activity against hemophilic bleeds artificially induced in muscles and subcutis, and that a subcutaneous (SC) dose of ACE910 showed a 3-week half-life and nearly 100% bioavailability, offering support for effective prophylaxis for hemophilia A by user-friendly SC dosing. However, there was no direct evidence that such SC dosing of ACE910 would prevent spontaneous bleeds occurring in daily life. In this study, we newly established a long-term primate model of acquired hemophilia A by multiple IV injections of an anti-primate FVIII neutralizing antibody engineered in mouse-monkey chimeric form to reduce its antigenicity. The monkeys in the control group exhibited various spontaneous bleeding symptoms as well as continuous prolongation of activated partial thromboplastin time; notably, all exhibited joint bleeds, which are a hallmark of hemophilia. Weekly SC doses of ACE910 (initial 3.97 mg/kg followed by 1 mg/kg) significantly prevented these bleeding symptoms; notably, no joint bleeding symptoms were observed. ACE910 is expected to prevent spontaneous bleeds and joint damage in hemophilia A patients even with weekly SC dosing, although appropriate clinical investigation is required.
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28
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Present and future challanges in the treatment of haemophilia: a clinician's perspective. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2014; 11 Suppl 4:s77-81. [PMID: 24333317 DOI: 10.2450/2013.012s] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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A von Willebrand factor fragment containing the D'D3 domains is sufficient to stabilize coagulation factor VIII in mice. Blood 2014; 124:445-52. [PMID: 24850761 DOI: 10.1182/blood-2013-11-540534] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Plasma factor VIII (FVIII) and von Willebrand factor (VWF) circulate together as a complex. We identify VWF fragments sufficient for FVIII stabilization in vivo and show that hepatic expression of the VWF D'D3 domains (S764-P1247), either as a monomer or a dimer, is sufficient to raise FVIII levels in Vwf(-/-) mice from a baseline of ∼5% to 10%, to ∼50% to 100%. These results demonstrate that a fragment containing only ∼20% of the VWF sequence is sufficient to support FVIII stability in vivo. Expression of the VWF D'D3 fragment fused at its C terminus to the Fc segment of immunoglobulin G1 results in markedly enhanced survival in the circulation (t1/2 > 7 days), concomitant with elevated plasma FVIII levels (>25% at 7 days) in Vwf(-/-) mice. Although the VWF D'D3-Fc chimera also exhibits markedly prolonged survival when transfused into FVIII-deficient mice, the cotransfused FVIII is rapidly cleared. Kinetic binding studies show that VWF propeptide processing of VWF D'D3 fragments is required for optimal FVIII affinity. The reduced affinity of VWF D'D3 and VWF D'D3-Fc for FVIII suggests that the shortened FVIII survival in FVIII-deficient mice transfused with FVIII and VWF D'D3/D'D3-Fc is due to ineffective competition of these fragments with endogenous VWF for FVIII binding.
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30
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Carcao M. Changing paradigm of prophylaxis with longer acting factor concentrates. Haemophilia 2014; 20 Suppl 4:99-105. [DOI: 10.1111/hae.12405] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2014] [Indexed: 01/16/2023]
Affiliation(s)
- M. Carcao
- Division of Haematology/Oncology; Department of Pediatrics; Child Health Evaluative Sciences; Research Institute; The Hospital for Sick Children; Toronto ON Canada
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31
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Progress towards gene therapy for haemophilia B. Int J Hematol 2014; 99:372-6. [PMID: 24500177 DOI: 10.1007/s12185-014-1523-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 01/13/2014] [Indexed: 11/27/2022]
Abstract
Haemophilia B is an X-linked recessive bleeding disorder, arising from a deficiency of coagulation factor IX. It has been a target for gene therapy ever since the factor IX gene was cloned in 1982. Several distinct approaches have been evaluated in humans over the last 30 years, but none has resulted in tangible corrections of the bleeding phenotype in humans until recently. Our group has now shown that lasting clinical improvement of the bleeding phenotype in patients with haemophilia B is possible following a single systemic administration of a self-complementary adeno-associated virus vector to deliver an optimised factor IX expression cassette to the liver. Success in this trial raises hope for patients with severe haemophilia B as well as others with inherited monogenetic disorders of the liver where current treatment options are limited.
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Muto A, Yoshihashi K, Takeda M, Kitazawa T, Soeda T, Igawa T, Sakamoto Y, Haraya K, Kawabe Y, Shima M, Yoshioka A, Hattori K. Anti-factor IXa/X bispecific antibody (ACE910): hemostatic potency against ongoing bleeds in a hemophilia A model and the possibility of routine supplementation. J Thromb Haemost 2014; 12:206-213. [PMID: 24735117 DOI: 10.1111/jth.12474] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Indexed: 12/18/2022]
Abstract
BACKGROUND We previously reported that a humanized anti-factor IXa/X bispecific antibody, hBS23, mimics the function of FVIII even in the presence of FVIII inhibitors, and has preventive hemostatic activity against bleeding in an animal model of acquired hemophilia A. After further molecular engineering of hBS23, we recently identified an improved humanized bispecific antibody, ACE910, for clinical investigation. OBJECTIVES To elucidate the in vivo hemostatic potency of ACE910 by examining its effect against ongoing bleeds, and to determine its pharmacokinetic parameters for discussion of its potency for prophylactic use. METHODS A non-human primate model of acquired hemophilia A was established by injecting anti-primate FVIII neutralizing antibody. When bleeds emerged following an artificial bleed-inducing procedure, either ACE910 or recombinant porcine FVIII (rpoFVIII) was intravenously administered. rpoFVIII was additionally administered twice daily on the following 2 days. Bleeding symptoms were monitored for 3 days. A pharmacokinetic study and multiple-dosing simulations of ACE910 were also performed. RESULTS A single bolus of 1 or 3 mg kg-1 ACE910 showed hemostatic activity comparable to that of 10 U kg-1 (twice daily) rpoFVIII against ongoing bleeds. The determined ACE910 pharmacokinetic parameters included a long half-life (3 weeks) and high subcutaneous bioavailability (nearly 100%). The simulation results based on pharmacokinetic parameters indicated that the above hemostatic level could be maintained with once-weekly subcutaneous administration of ACE910, suggesting the possibility of more effective prophylaxis. CONCLUSIONS ACE910 may offer an alternative on-demand treatment option for patients with hemophilia A, as well as user-friendly and aggressive routine supplementation.
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Affiliation(s)
- A Muto
- Research Division, Chugai Pharmaceutical Co., Ltd, Gotemba, Shizuoka, Japan
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Present and future challenges in the treatment of haemophilia: the patient's perspective. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2013; 11 Suppl 4:s82-5. [PMID: 24333318 DOI: 10.2450/2013.013s] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Esposito P, Rampino T, Gregorini M, Fasoli G, Gamba G, Dal Canton A. Renal diseases in haemophilic patients: pathogenesis and clinical management. Eur J Haematol 2013; 91:287-94. [PMID: 23651176 DOI: 10.1111/ejh.12134] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2013] [Indexed: 02/05/2023]
Abstract
Haemophilia A and B are genetic X-linked bleeding disorders, caused by mutations in genes encoding factors VIII and IX, respectively. Clinical manifestations of haemophilia are spontaneous haemorrhage or acute bleeding caused by minor trauma, resulting in severe functional consequences that can culminate in a debilitating arthropathy. Life expectancy and quality of life of patients with haemophilia have dramatically improved over the last years, mainly for new therapeutic options and the awareness to the risk of HCV and HIV infections. Different clinical problems arise from this important change in history of patients with haemophilia. In particular, ageing-related diseases, such as diabetes, hypertension and cancer, and chronic viral infections are emerging as new challenges in this patient population. Among the different types of chronic illnesses, renal diseases are of special interest as they involve some difficult management issues. In fact, decisions regarding adequate preventive strategies and viral infection treatment, the choice of the dialytic modality, placement of vascular access and prescription of dialytic treatments are particularly complicated, because only few data are available. In this review, we discuss the pathogenesis of renal damage in patients with haemophilia, especially in those with blood-transmitted viral infections, and the major issues about the management of renal diseases, including problems related to dialytic treatment and kidney transplantation, providing practical algorithms to guide the clinical decision-making process.
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Affiliation(s)
- Pasquale Esposito
- Unit of Nephrology, Dialysis and Transplantation, Fondazione IRCCS Policlinico S.Matteo and University of Pavia, Pavia, Italy
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36
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Peyvandi F, Garagiola I, Seregni S. Future of coagulation factor replacement therapy. J Thromb Haemost 2013; 11 Suppl 1:84-98. [PMID: 23809113 DOI: 10.1111/jth.12270] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Accepted: 04/13/2013] [Indexed: 12/24/2022]
Abstract
Over a million patients worldwide currently suffer from hemophilia and other congenital clotting factor deficiencies. Patients affected with hemophilia A and B are treated by intravenous replacement therapy of factor VIII and factor IX, respectively. Current hemophilia treatments have favorably supported their efficacy, tolerability, and safety profiles. The onset of alloantibodies inactivating the infused coagulation factor is the main problem in hemophilia patients rendering replacement therapies ineffective; another disadvantage is the short half-life of the infused clotting factors with the need for multiple and frequent infusions to manage a bleeding episode. Now, the challenge in the management of hemophilia treatment is the prolongation of the half-life and reduction in the immunogenicity of recombinant clotting factors. The bioengineering strategies, previously applied successfully to other therapeutic proteins, encourage the current efforts to produce novel coagulation factors with more prolonged bioavailability, with increased potency and resistance to inactivation and potentially reduced immunogenicity.
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Affiliation(s)
- F Peyvandi
- Angelo Bianchi Bonomi Haemophilia and Thrombosis Center, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.
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Walsh CE, Batt KM. Hemophilia clinical gene therapy: brief review. Transl Res 2013; 161:307-12. [PMID: 23352600 DOI: 10.1016/j.trsl.2012.12.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Revised: 12/13/2012] [Accepted: 12/28/2012] [Indexed: 11/30/2022]
Abstract
Genetic correction of hemophilia A and B was long considered amenable to the available gene transfer technologies. This assumption has come to fruition with the recent results of a phase I/II trial for hemophilia B. Here we review the clinical application of gene therapy for the hemophilia's as a paradigm of the evolution of gene transfer science and technology. This review is not intended as comprehensive but rather to highlight current clinical developments of gene therapy for the hemophilias.
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